DDW HIGHLIGHTS
Gastrointestinal bleeding Ian M. Gralnek, MD Haifa, Israel
A number of interesting abstracts on gastrointestinal bleeding and endoscopy were presented at Digestive Disease Week (DDW) this year (3–6 May 2014, Chicago, Illinois). The following abstracts are those that have particular high clinical importance and the potential for direct impact on the endoscopic care of patients with gastrointestinal bleeding.
apparent increased risk with intermittent PPI therapy. The authors concluded that intermittent PPI therapy was as effective as the current standard of care regimen of bolus PPI followed by continuous infusion for patients with ulcer bleeding and high-risk stigmata, and that a revision of current guidelines regarding recommendations on post-hemostasis PPI therapy may therefore be necessary.
BLEEDING PEPTIC ULCERS
Transarterial angiographic embolization
Proton pump inhibitor therapy Current international guidelines recommend the use of proton pump inhibitors (PPIs), administered as a bolus (80 mg) followed by a continuous infusion (8 mg/hour for 72 hours), following endotherapy for bleeding peptic ulcers.1-3 In a systematic review and meta-analysis, Sachar et al4 reported on intermittent PPI use vs. the bolusþinfusion regimen for patients with high risk peptic ulcers (active bleeding, nonbleeding visible vessel, adherent clot). The primary outcome of the study was ulcer rebleeding within 7 days, and the noninferiority margin was defined as a 3% absolute risk difference. Secondary outcomes included rebleeding at 3 days, rebleeding at 30 days, mortality, need for surgery or interventional radiology, length of hospital stay, and blood transfusions. A total of 12 studies met the inclusion criteria. For the primary outcome of ulcer rebleeding at 7 days (n Z 1308), the upper limit of the one-sided 95% confidence interval (CI) for the absolute risk difference was 0% (i.e. below the 3% noninferiority margin value). Moreover, for all other study outcomes, relative risks were !1 and mean differences were !0. These results indicate that there is no
Abbreviations: DDW, Digestive Disease Week; EGD, esophagogastroduodenoscopy; NGT, nasogastric tube; OTSC, over-the-scope clip; PPI, proton pump inhibitor; TAE, transarterial angiographic embolization. DISCLOSURE: The author disclosed no financial relationships relevant to this article. This report is published simultaneously in the journals Gastrointestinal Endoscopy and Endoscopy. Copyright ª 2014 by the American Society for Gastrointestinal Endoscopy and ª Georg Thieme Verlag KG 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2014.07.007
392 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 3 : 2014
Three abstracts at DDW focused on the role of transarterial angiographic embolization (TAE) therapy in patients with peptic ulcer bleeding.5-7 As we know, ulcer rebleeding following endoscopic hemostasis is associated with significantly increased morbidity and mortality. In the first abstract, Lau et al5 evaluated whether “pre-emptive” TAE of high-risk ulcers reduces rebleeding rates and improves patient outcomes. The study included patients with gastric or duodenal ulcers who had undergone successful endoscopic hemostasis yet had at least one of the following clinical characteristics at the time of esophagogastroduodenoscopy (EGD): Forrest Ia bleeding (spurting type bleeding), large ulcer size R1.5 cm, systolic blood pressure !90 mmHg, or hemoglobin %9 g/dL. Patients were randomly assigned (within 12 hours of EGD) to undergo pre-emptive TAE plus high-dose intravenous PPI (n Z 109) or to receive high-dose intravenous PPI only (n Z 113). The primary end point was ulcer rebleeding within 30 days of randomization. Baseline patient demographics were similar between groups. On intention-to-treat analysis, ulcer rebleeding occurred in 8/109 patients (7.3%) in the TAE group and in 12/113 patients (10.6%) in the PPI only group (P Z 0.39; odds ratio [OR] 0.67, 95%CI 0.26–1.70). On perprotocol analysis, ulcer rebleeding occurred in 4/91 patients (4.4%) in the TAE group and 12/110 patients (10.9%) in the PPI only group (P Z 0.89; OR 2.66, 95% CI 0.8–8.5). There were no observed significant differences between groups in terms of mortality, length of hospital stay, or blood transfusion requirements. There was significantly less ulcer rebleeding in the subgroup of patients with large ulcers (R1.5 cm) who received pre-emptive TAE (2/40 [5.0%] vs. 10/43 [23.3%]; P Z 0.027). Thus, in this specific high-risk subgroup, there may be a role for early pre-emptive TAE therapy. Additional data are warranted. www.giejournal.org
Gralnek
In another study by the same group, the authors reported on a study of patients with massive gastroduodenal ulcer bleeding in whom endoscopic hemostasis was unsuccessful.6 Over more than 6 years, 31 patients were randomized to undergo TAE (n Z 17) or surgery (n Z 14) as rescue therapy. On intention-to-treat analysis, there were no deaths in either group at 30 days postrandomization. Treatment failures were higher in the TAE group (9/17 [52.9%] vs. 3/14 [21.4%]; P Z 0.052; OR 4.7, 95%CI 0.9–23.7) as were the median number of blood transfusions (2 units [range 0–18] vs. 0 units [range 0–9]; P Z 0.058). Compared with surgery, patients receiving TAE spent significantly fewer days in the intensive care unit (0 days vs. 2 days; P Z 0.037), although overall length of hospital stay was similar between the groups (9 days [range 3–36] vs. 12 days [range 3–27]; P Z 0.91). Finally, in a retrospective cohort study (from 2008 to 2012), Wu et al7 evaluated the role of adjunctive prophylactic TAE following endoscopic hemostasis in selected patients with peptic ulcer bleeding who were at “extreme” risk of ulcer rebleeding. Using univariate and multiple regression analysis, the authors attempted to identify independent predictors of the need for prophylactic TAE. The authors identified 245 patients who had peptic ulcer bleeding requiring endoscopic hemostasis. All patients received intravenous PPI therapy, and the overall ulcer rebleeding rate was 33/245 (13.5%). A total of 10 patients received prophylactic TAE following endoscopic hemostasis. On multiple logistic regression analysis, initial hypotension (systolic blood pressure ! 100 mmHg) and prolonged endoscopy time required to achieve primary hemostasis (R60 minutes) were significant independent factors contributing to ulcer rebleeding. In those patients with prolonged endoscopy time, the ulcer rebleeding rate was 2/8 (25.0%) in those who received the TAE therapy and 18/26 (69.2%) in those who did not receive the prophylactic therapy (P Z 0.042). The authors concluded that prolonged endoscopy time to achieve primary hemostasis may be a predictor of ulcer rebleeding and could be used to select patients who would benefit from prophylactic TAE therapy.
Gastrointestinal bleeding
12 months. The primary end point was recurrent upper gastrointestinal bleeding as determined by an independent adjudication committee. In an intention-to-treat analysis of 163 patients (84 rabeprazole, 79 famotidine), 15 patients had suspected recurrent bleeding (9 rabeprazole, 6 famotidine). The committee confirmed recurrent upper gastrointestinal bleeding in one patient (1.2%) from the rabeprazole group and in three patients (3.8%) from the famotidine group (P Z 0.29). Eight rabeprazole patients (9.5%) and three famotidine patients (3.8%) had lower gastrointestinal bleeding (P Z 0.17). The authors concluded from this interim analysis that, in aspirin users with a history of nonvariceal upper gastrointestinal bleeding, there is no significant difference in recurrent upper gastrointestinal bleeding between patients receiving rabeprazole and those receiving famotidine. It should, however, be noted that this was only an interim analysis of an ongoing study and the lack of statistical significance between groups may be due to inadequate power to detect a true difference (beta error). We therefore eagerly await the final study results.
NASOGASTRIC TUBE PLACEMENT TO PREDICT NEED FOR ENDOSCOPIC THERAPY
Chan et al8 evaluated the role of antisecretory agents in nonvariceal upper gastrointestinal bleeding, and presented data at DDW on an interim analysis of a doubleblind, randomized trial comparing a PPI (rabeprazole) with a histamine-2 receptor antagonists (famotidine) for the prevention of recurrent ulcer bleeding in low-dose (80 mg/day) aspirin users. Following ulcer healing, aspirin users were randomly assigned to receive either rabeprazole 20 mg/day or famotidine 40 mg/day for up to
Although nasogastric tube (NGT) placement with aspiration and lavage is often used in the emergency department as part of the initial evaluation of patients with suspected upper gastrointestinal bleeding, its clinical utility remains unproven. Rockey et al9 reported on the results of a single-center, single-blind, randomized, noninferiority study comparing NGT placement with aspiration and lavage vs. no NGT placement in patients presenting with suspected acute upper gastrointestinal bleeding (hematemesis and/or melena). Physicians completed a validated questionnaire (pre- and post-NGT placement) to predict the need for endoscopic intervention at the time of EGD. The primary outcome was the ability of NGT aspiration to predict the need for endoscopic therapy at EGD performed within the subsequent 24 hours. A total of 280 patients were randomized (140 NGT, 140 no NGT). The groups were evenly matched for demographic and clinical variables. NGT placement and aspiration led to a change in the physicians’ prediction of whether or not patients were likely to need endoscopic therapy in 41/140 patients (29%). There was an absolute change of more than 20% in physicians’ prediction in only 21/140 patients (15%). Endoscopic therapy was delivered in 34% and 31% in the NGT and no NGT arms, respectively (P Z 0.70). The authors concluded that the routine placement of NGT with aspiration and lavage in patients with suspected upper gastrointestinal bleeding did not assist in predicting the need for subsequent endoscopic therapy. Furthermore, NGT placement led to patient discomfort, nasal bleeding,
www.giejournal.org
Volume 80, No. 3 : 2014 GASTROINTESTINAL ENDOSCOPY 393
NONVARICEAL UPPER GASTROINTESTINAL BLEEDING
Gastrointestinal bleeding
Gralnek
or failed placement in 35% of patients, and had no impact on patient outcomes.
in patients with gastric variceal bleeding.21 I wish you all happy reading!
CLIPPING DEVICES FOR HEMOSTASIS
REFERENCES
Skinner et al10 evaluated the efficacy and safety of the over-the-scope clip (OTSC) system (Ovesco Endoscopy AG, Tübingen, Germany) in patients with gastrointestinal bleeding in whom traditional endoscopic hemostasis had failed (mean number of endoscopies performed per patient prior to OTSC Z 2, range 1–5). The OTSC is made from a nickel–titanium alloy and is affixed to a transparent cap that fits over the distal tip of the endoscope. The lesion to be treated is suctioned into the transparent cap, the clip is then deployed by turning a knob, akin to the mechanism used in variceal band ligation. In this retrospective case series, Skinner et al identified 12 patients (5 duodenal ulcers, 3 Dieulafoy’s lesions, 2 anastomotic ulcers, 1 anastomotic varices, 1 Mallory–Weiss tear) who were treated with rescue OTSC. Primary hemostasis was achieved with the OTSC in all patients. Rebleeding occurred only in the patient with the Mallory–Weiss tear, and was treated with a combination of dilute epinephrine and traditional through-the-scope endoscopic clips. There were no adverse events with OTSC use. The authors concluded that the OTSC provides an additional tool in our armamentarium for treating gastrointestinal bleeding lesions that traditional endoscopic hemostasis techniques have failed to treat successfully, and that these clipping devices may be used as a “rescue” therapy.
A number of additional abstracts are well worth reading.11-21 These abstracts cover relevant topics such as endoscopic hemostatic treatments for ulcer bleeding, including hemostatic powders or sprays and injection of absolute ethanol.11-13 Other abstracts that warrant inspection include topics on low-dose aspirin and the risk of recurrent lower gastrointestinal bleeding and cardiovascular outcomes,14 urgent vs. early endoscopy in acute nonvariceal upper gastrointestinal bleeding,15 emergency balloon-assisted enteroscopy in ongoing obscure overt gastrointestinal bleeding,16 risk of liberal blood transfusions in nonvariceal upper gastrointestinal hemorrhage,17 Doppler endoscopic probe for risk stratification in postpolypectomy bleeding,18 radiofrequency ablation in gastric antral vascular ectasia and radiation proctitis,19 the role of elective endotracheal intubation prior to emergency EGD in patients with suspected variceal bleeding,20 and glue versus transcutaneous intrahepatic portosystemic shunt
1. American College of Gastroenterology. Management of patients with ulcer bleeding. Available at: http://gi.org/guideline/management-ofpatients-with-ulcer-bleeding/. Accessed June 2014. 2. Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a peptic ulcer. N Engl J Med 2008;359:928-37. 3. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010;152:101-13. 4. Sachar H, Vaidya K, Laine L. Intermittent PPI therapy is non-inferior to guideline recommended bolus-continuous infusion PPI therapy after endoscopic hemostasis in patients with ulcer bleeding: a systematic review and meta-analysis. Gastroenterology 2014;146(5 suppl 1):S75. 5. Lau JY, Wong K, Chiu PW, et al. Early angiographic embolization after endoscopic hemostasis to high risk bleeding peptic ulcers improves outcomes [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB113. 6. Lau JY, Wong K, Chiu PW, et al. Transarterial angiographic embolization vs. surgery in patients with bleeding peptic ulcers uncontrolled at endoscopy: a multicenter randomized trial [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB113. 7. Wu P, Szczesniak MM, Craig PI, et al. A novel predictor of rebleeding in high risk peptic ulcer disease selects patients who would benefit most from prophylactic arterial embolisation. Gastroenterology 2014;146(5 suppl 1):S183. 8. Chan FKL, Cheong PK, Ching J, et al. Proton-pump inhibitor (PPI) versus histamine-2 receptor antagonist (H2RA) for the prevention of recurrent upper gastrointestinal (UGI) bleeding in high-risk users of low dose aspirin (ASA): an interim analysis. Gastroenterology 2014;146(5 suppl 1): S208. 9. Rockey DC, Melo SW, Ahn C. A randomized controlled trial of nasogastric tube placement in patients with upper gastrointestinal bleeding. Gastroenterology 2014;146(5 suppl 1):S184. 10. Skinner MJ, Gutierrez JP, Neumann H, et al. Over-the-scope-clip is an effective rescue therapy for severe acute upper gastrointestinal bleeding [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB143. 11. Sulz MC, Frei R, Gubler C, et al. Hemospray for GI bleeding: prospective two-center experience in Switzerland [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB226. 12. Haddara S, Branche J, Lecleire S, et al. A novel hemostatic powder for the endoscopic treatment of gastrointestinal bleeding: results from a multicenter prospective study performed in routine practice (the ‘graphic’ registry). Gastroenterology 2014;146(5 suppl 1): S771. 13. Koyama S, Kato T. Absolute ethanol is a highly effective agent in injection therapy of bleeding tract gastric ulcer: ulcer enlargement is not a complication but could be proof of hemostasis [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB227-8. 14. Chan FKL, Ki ELL, Tse YK, et al. Resumption of low-dose aspirin and the risk of recurrent lower GI bleeding and CV outcomes: a long term cohort study. Gastroenterology 2014;146(5 suppl 1):S27. 15. Oh SK, Kim DJ, Kang DH, et al. Endoscopic yield and outcomes of performing urgent versus early endoscopy in acute non-variceal upper gastrointestinal bleeding [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB296. 16. Matsuda T, Okuzono T. Efficacy and safety of emergency balloonassisted endoscopy in patients with overt ongoing obscure gastrointestinal bleeding. Gastrointest Endosc 2014;79(suppl 5):AB150. 17. Marmo R, Bianco MA, Bucci C, et al. Liberal transfusion strategy as a potential risk factor for mortality in acute non-variceal upper
394 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 3 : 2014
www.giejournal.org
FURTHER READING
Gralnek
18.
19.
20.
21.
Gastrointestinal bleeding
gastrointestinal bleeding (NVUGIB) [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB141. Jensen DM, Ohning GV. Doppler endoscopic probe as a guide to risk stratification and prophylaxis to prevent delayed post-polypectomy induced ulcer hemorrhage after polypectomy [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB567. Siddhi SS, Dalziel H, Henry EB. Initial experience with radiofrequency ablation in gastric antral vascular ectasia and radiation proctitis [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB334. Tang YM, Wang Y, Wang WW. Elective endotracheal intubation prior to emergent EGD in patients with suspected variceal hemorrhage: an evaluation of outcome and complications [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB515-6. Kochhar G, Navaneethan U, Parungao JM, et al. Short term mortality in patients with acute gastric variceal bleeding: endoscopic glue
injections are as effective as TIPSda comparative study [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB227.
Received July 1, 2014. Accepted July 1, 2014. Current affiliations: GI Outcomes Unit, Department of Gastroenterology, Rambam Health Care Campus, and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel. Reprint requests: Ian M. Gralnek, MD, GI Outcomes Unit, Department of Gastroenterology, Bruce and Ruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Rambam Health Care Campus, Haifa, 34333, Israel.
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www.giejournal.org
Volume 80, No. 3 : 2014 GASTROINTESTINAL ENDOSCOPY 395
Gastrointestinal bleeding Ian M. Gralnek, MD Haifa, Israel
A number of interesting abstracts on gastrointestinal bleeding and endoscopy were presented at Digestive Disease Week (DDW) this year (3–6 May 2014, Chicago, Illinois). The following abstracts are those that have particular high clinical importance and the potential for direct impact on the endoscopic care of patients with gastrointestinal bleeding.
apparent increased risk with intermittent PPI therapy. The authors concluded that intermittent PPI therapy was as effective as the current standard of care regimen of bolus PPI followed by continuous infusion for patients with ulcer bleeding and high-risk stigmata, and that a revision of current guidelines regarding recommendations on post-hemostasis PPI therapy may therefore be necessary.
BLEEDING PEPTIC ULCERS
Transarterial angiographic embolization
Proton pump inhibitor therapy Current international guidelines recommend the use of proton pump inhibitors (PPIs), administered as a bolus (80 mg) followed by a continuous infusion (8 mg/hour for 72 hours), following endotherapy for bleeding peptic ulcers.1-3 In a systematic review and meta-analysis, Sachar et al4 reported on intermittent PPI use vs. the bolusþinfusion regimen for patients with high risk peptic ulcers (active bleeding, nonbleeding visible vessel, adherent clot). The primary outcome of the study was ulcer rebleeding within 7 days, and the noninferiority margin was defined as a 3% absolute risk difference. Secondary outcomes included rebleeding at 3 days, rebleeding at 30 days, mortality, need for surgery or interventional radiology, length of hospital stay, and blood transfusions. A total of 12 studies met the inclusion criteria. For the primary outcome of ulcer rebleeding at 7 days (n Z 1308), the upper limit of the one-sided 95% confidence interval (CI) for the absolute risk difference was 0% (i.e. below the 3% noninferiority margin value). Moreover, for all other study outcomes, relative risks were !1 and mean differences were !0. These results indicate that there is no
Abbreviations: DDW, Digestive Disease Week; EGD, esophagogastroduodenoscopy; NGT, nasogastric tube; OTSC, over-the-scope clip; PPI, proton pump inhibitor; TAE, transarterial angiographic embolization. DISCLOSURE: The author disclosed no financial relationships relevant to this article. This report is published simultaneously in the journals Gastrointestinal Endoscopy and Endoscopy. Copyright ª 2014 by the American Society for Gastrointestinal Endoscopy and ª Georg Thieme Verlag KG 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2014.07.007
392 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 3 : 2014
Three abstracts at DDW focused on the role of transarterial angiographic embolization (TAE) therapy in patients with peptic ulcer bleeding.5-7 As we know, ulcer rebleeding following endoscopic hemostasis is associated with significantly increased morbidity and mortality. In the first abstract, Lau et al5 evaluated whether “pre-emptive” TAE of high-risk ulcers reduces rebleeding rates and improves patient outcomes. The study included patients with gastric or duodenal ulcers who had undergone successful endoscopic hemostasis yet had at least one of the following clinical characteristics at the time of esophagogastroduodenoscopy (EGD): Forrest Ia bleeding (spurting type bleeding), large ulcer size R1.5 cm, systolic blood pressure !90 mmHg, or hemoglobin %9 g/dL. Patients were randomly assigned (within 12 hours of EGD) to undergo pre-emptive TAE plus high-dose intravenous PPI (n Z 109) or to receive high-dose intravenous PPI only (n Z 113). The primary end point was ulcer rebleeding within 30 days of randomization. Baseline patient demographics were similar between groups. On intention-to-treat analysis, ulcer rebleeding occurred in 8/109 patients (7.3%) in the TAE group and in 12/113 patients (10.6%) in the PPI only group (P Z 0.39; odds ratio [OR] 0.67, 95%CI 0.26–1.70). On perprotocol analysis, ulcer rebleeding occurred in 4/91 patients (4.4%) in the TAE group and 12/110 patients (10.9%) in the PPI only group (P Z 0.89; OR 2.66, 95% CI 0.8–8.5). There were no observed significant differences between groups in terms of mortality, length of hospital stay, or blood transfusion requirements. There was significantly less ulcer rebleeding in the subgroup of patients with large ulcers (R1.5 cm) who received pre-emptive TAE (2/40 [5.0%] vs. 10/43 [23.3%]; P Z 0.027). Thus, in this specific high-risk subgroup, there may be a role for early pre-emptive TAE therapy. Additional data are warranted. www.giejournal.org
Gralnek
In another study by the same group, the authors reported on a study of patients with massive gastroduodenal ulcer bleeding in whom endoscopic hemostasis was unsuccessful.6 Over more than 6 years, 31 patients were randomized to undergo TAE (n Z 17) or surgery (n Z 14) as rescue therapy. On intention-to-treat analysis, there were no deaths in either group at 30 days postrandomization. Treatment failures were higher in the TAE group (9/17 [52.9%] vs. 3/14 [21.4%]; P Z 0.052; OR 4.7, 95%CI 0.9–23.7) as were the median number of blood transfusions (2 units [range 0–18] vs. 0 units [range 0–9]; P Z 0.058). Compared with surgery, patients receiving TAE spent significantly fewer days in the intensive care unit (0 days vs. 2 days; P Z 0.037), although overall length of hospital stay was similar between the groups (9 days [range 3–36] vs. 12 days [range 3–27]; P Z 0.91). Finally, in a retrospective cohort study (from 2008 to 2012), Wu et al7 evaluated the role of adjunctive prophylactic TAE following endoscopic hemostasis in selected patients with peptic ulcer bleeding who were at “extreme” risk of ulcer rebleeding. Using univariate and multiple regression analysis, the authors attempted to identify independent predictors of the need for prophylactic TAE. The authors identified 245 patients who had peptic ulcer bleeding requiring endoscopic hemostasis. All patients received intravenous PPI therapy, and the overall ulcer rebleeding rate was 33/245 (13.5%). A total of 10 patients received prophylactic TAE following endoscopic hemostasis. On multiple logistic regression analysis, initial hypotension (systolic blood pressure ! 100 mmHg) and prolonged endoscopy time required to achieve primary hemostasis (R60 minutes) were significant independent factors contributing to ulcer rebleeding. In those patients with prolonged endoscopy time, the ulcer rebleeding rate was 2/8 (25.0%) in those who received the TAE therapy and 18/26 (69.2%) in those who did not receive the prophylactic therapy (P Z 0.042). The authors concluded that prolonged endoscopy time to achieve primary hemostasis may be a predictor of ulcer rebleeding and could be used to select patients who would benefit from prophylactic TAE therapy.
Gastrointestinal bleeding
12 months. The primary end point was recurrent upper gastrointestinal bleeding as determined by an independent adjudication committee. In an intention-to-treat analysis of 163 patients (84 rabeprazole, 79 famotidine), 15 patients had suspected recurrent bleeding (9 rabeprazole, 6 famotidine). The committee confirmed recurrent upper gastrointestinal bleeding in one patient (1.2%) from the rabeprazole group and in three patients (3.8%) from the famotidine group (P Z 0.29). Eight rabeprazole patients (9.5%) and three famotidine patients (3.8%) had lower gastrointestinal bleeding (P Z 0.17). The authors concluded from this interim analysis that, in aspirin users with a history of nonvariceal upper gastrointestinal bleeding, there is no significant difference in recurrent upper gastrointestinal bleeding between patients receiving rabeprazole and those receiving famotidine. It should, however, be noted that this was only an interim analysis of an ongoing study and the lack of statistical significance between groups may be due to inadequate power to detect a true difference (beta error). We therefore eagerly await the final study results.
NASOGASTRIC TUBE PLACEMENT TO PREDICT NEED FOR ENDOSCOPIC THERAPY
Chan et al8 evaluated the role of antisecretory agents in nonvariceal upper gastrointestinal bleeding, and presented data at DDW on an interim analysis of a doubleblind, randomized trial comparing a PPI (rabeprazole) with a histamine-2 receptor antagonists (famotidine) for the prevention of recurrent ulcer bleeding in low-dose (80 mg/day) aspirin users. Following ulcer healing, aspirin users were randomly assigned to receive either rabeprazole 20 mg/day or famotidine 40 mg/day for up to
Although nasogastric tube (NGT) placement with aspiration and lavage is often used in the emergency department as part of the initial evaluation of patients with suspected upper gastrointestinal bleeding, its clinical utility remains unproven. Rockey et al9 reported on the results of a single-center, single-blind, randomized, noninferiority study comparing NGT placement with aspiration and lavage vs. no NGT placement in patients presenting with suspected acute upper gastrointestinal bleeding (hematemesis and/or melena). Physicians completed a validated questionnaire (pre- and post-NGT placement) to predict the need for endoscopic intervention at the time of EGD. The primary outcome was the ability of NGT aspiration to predict the need for endoscopic therapy at EGD performed within the subsequent 24 hours. A total of 280 patients were randomized (140 NGT, 140 no NGT). The groups were evenly matched for demographic and clinical variables. NGT placement and aspiration led to a change in the physicians’ prediction of whether or not patients were likely to need endoscopic therapy in 41/140 patients (29%). There was an absolute change of more than 20% in physicians’ prediction in only 21/140 patients (15%). Endoscopic therapy was delivered in 34% and 31% in the NGT and no NGT arms, respectively (P Z 0.70). The authors concluded that the routine placement of NGT with aspiration and lavage in patients with suspected upper gastrointestinal bleeding did not assist in predicting the need for subsequent endoscopic therapy. Furthermore, NGT placement led to patient discomfort, nasal bleeding,
www.giejournal.org
Volume 80, No. 3 : 2014 GASTROINTESTINAL ENDOSCOPY 393
NONVARICEAL UPPER GASTROINTESTINAL BLEEDING
Gastrointestinal bleeding
Gralnek
or failed placement in 35% of patients, and had no impact on patient outcomes.
in patients with gastric variceal bleeding.21 I wish you all happy reading!
CLIPPING DEVICES FOR HEMOSTASIS
REFERENCES
Skinner et al10 evaluated the efficacy and safety of the over-the-scope clip (OTSC) system (Ovesco Endoscopy AG, Tübingen, Germany) in patients with gastrointestinal bleeding in whom traditional endoscopic hemostasis had failed (mean number of endoscopies performed per patient prior to OTSC Z 2, range 1–5). The OTSC is made from a nickel–titanium alloy and is affixed to a transparent cap that fits over the distal tip of the endoscope. The lesion to be treated is suctioned into the transparent cap, the clip is then deployed by turning a knob, akin to the mechanism used in variceal band ligation. In this retrospective case series, Skinner et al identified 12 patients (5 duodenal ulcers, 3 Dieulafoy’s lesions, 2 anastomotic ulcers, 1 anastomotic varices, 1 Mallory–Weiss tear) who were treated with rescue OTSC. Primary hemostasis was achieved with the OTSC in all patients. Rebleeding occurred only in the patient with the Mallory–Weiss tear, and was treated with a combination of dilute epinephrine and traditional through-the-scope endoscopic clips. There were no adverse events with OTSC use. The authors concluded that the OTSC provides an additional tool in our armamentarium for treating gastrointestinal bleeding lesions that traditional endoscopic hemostasis techniques have failed to treat successfully, and that these clipping devices may be used as a “rescue” therapy.
A number of additional abstracts are well worth reading.11-21 These abstracts cover relevant topics such as endoscopic hemostatic treatments for ulcer bleeding, including hemostatic powders or sprays and injection of absolute ethanol.11-13 Other abstracts that warrant inspection include topics on low-dose aspirin and the risk of recurrent lower gastrointestinal bleeding and cardiovascular outcomes,14 urgent vs. early endoscopy in acute nonvariceal upper gastrointestinal bleeding,15 emergency balloon-assisted enteroscopy in ongoing obscure overt gastrointestinal bleeding,16 risk of liberal blood transfusions in nonvariceal upper gastrointestinal hemorrhage,17 Doppler endoscopic probe for risk stratification in postpolypectomy bleeding,18 radiofrequency ablation in gastric antral vascular ectasia and radiation proctitis,19 the role of elective endotracheal intubation prior to emergency EGD in patients with suspected variceal bleeding,20 and glue versus transcutaneous intrahepatic portosystemic shunt
1. American College of Gastroenterology. Management of patients with ulcer bleeding. Available at: http://gi.org/guideline/management-ofpatients-with-ulcer-bleeding/. Accessed June 2014. 2. Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a peptic ulcer. N Engl J Med 2008;359:928-37. 3. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010;152:101-13. 4. Sachar H, Vaidya K, Laine L. Intermittent PPI therapy is non-inferior to guideline recommended bolus-continuous infusion PPI therapy after endoscopic hemostasis in patients with ulcer bleeding: a systematic review and meta-analysis. Gastroenterology 2014;146(5 suppl 1):S75. 5. Lau JY, Wong K, Chiu PW, et al. Early angiographic embolization after endoscopic hemostasis to high risk bleeding peptic ulcers improves outcomes [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB113. 6. Lau JY, Wong K, Chiu PW, et al. Transarterial angiographic embolization vs. surgery in patients with bleeding peptic ulcers uncontrolled at endoscopy: a multicenter randomized trial [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB113. 7. Wu P, Szczesniak MM, Craig PI, et al. A novel predictor of rebleeding in high risk peptic ulcer disease selects patients who would benefit most from prophylactic arterial embolisation. Gastroenterology 2014;146(5 suppl 1):S183. 8. Chan FKL, Cheong PK, Ching J, et al. Proton-pump inhibitor (PPI) versus histamine-2 receptor antagonist (H2RA) for the prevention of recurrent upper gastrointestinal (UGI) bleeding in high-risk users of low dose aspirin (ASA): an interim analysis. Gastroenterology 2014;146(5 suppl 1): S208. 9. Rockey DC, Melo SW, Ahn C. A randomized controlled trial of nasogastric tube placement in patients with upper gastrointestinal bleeding. Gastroenterology 2014;146(5 suppl 1):S184. 10. Skinner MJ, Gutierrez JP, Neumann H, et al. Over-the-scope-clip is an effective rescue therapy for severe acute upper gastrointestinal bleeding [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB143. 11. Sulz MC, Frei R, Gubler C, et al. Hemospray for GI bleeding: prospective two-center experience in Switzerland [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB226. 12. Haddara S, Branche J, Lecleire S, et al. A novel hemostatic powder for the endoscopic treatment of gastrointestinal bleeding: results from a multicenter prospective study performed in routine practice (the ‘graphic’ registry). Gastroenterology 2014;146(5 suppl 1): S771. 13. Koyama S, Kato T. Absolute ethanol is a highly effective agent in injection therapy of bleeding tract gastric ulcer: ulcer enlargement is not a complication but could be proof of hemostasis [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB227-8. 14. Chan FKL, Ki ELL, Tse YK, et al. Resumption of low-dose aspirin and the risk of recurrent lower GI bleeding and CV outcomes: a long term cohort study. Gastroenterology 2014;146(5 suppl 1):S27. 15. Oh SK, Kim DJ, Kang DH, et al. Endoscopic yield and outcomes of performing urgent versus early endoscopy in acute non-variceal upper gastrointestinal bleeding [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB296. 16. Matsuda T, Okuzono T. Efficacy and safety of emergency balloonassisted endoscopy in patients with overt ongoing obscure gastrointestinal bleeding. Gastrointest Endosc 2014;79(suppl 5):AB150. 17. Marmo R, Bianco MA, Bucci C, et al. Liberal transfusion strategy as a potential risk factor for mortality in acute non-variceal upper
394 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 3 : 2014
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FURTHER READING
Gralnek
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Gastrointestinal bleeding
gastrointestinal bleeding (NVUGIB) [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB141. Jensen DM, Ohning GV. Doppler endoscopic probe as a guide to risk stratification and prophylaxis to prevent delayed post-polypectomy induced ulcer hemorrhage after polypectomy [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB567. Siddhi SS, Dalziel H, Henry EB. Initial experience with radiofrequency ablation in gastric antral vascular ectasia and radiation proctitis [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB334. Tang YM, Wang Y, Wang WW. Elective endotracheal intubation prior to emergent EGD in patients with suspected variceal hemorrhage: an evaluation of outcome and complications [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB515-6. Kochhar G, Navaneethan U, Parungao JM, et al. Short term mortality in patients with acute gastric variceal bleeding: endoscopic glue
injections are as effective as TIPSda comparative study [abstract]. Gastrointest Endosc 2014;79(suppl 5):AB227.
Received July 1, 2014. Accepted July 1, 2014. Current affiliations: GI Outcomes Unit, Department of Gastroenterology, Rambam Health Care Campus, and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel. Reprint requests: Ian M. Gralnek, MD, GI Outcomes Unit, Department of Gastroenterology, Bruce and Ruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Rambam Health Care Campus, Haifa, 34333, Israel.
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